Your Health Priorities Tool

If you don’t share details about your life and what is important to you, you may not get the treatment that is best for you. Think about it this way: If you are a student who lives near a bus stop, you might be able to take a medicine that makes you a little sleepy because you do not need to drive. But if you are a truck driver, that medicine might make you too sleepy to do your job. Sharing details about your daily life and what’s important to you can help your doctor recommend a treatment that helps you get better and improves your quality of life.

Answer the questions below to get your own health priorities snapshot to share with your doctor.

Get your own health priorities snapshot:

1. Rate how important it is for you to be able to do each of the following activities, either at work or at home.

	Not at all important	Only slightly important	Moderately important	Important	Very important
Driving	Not at all important	Only slightly important	Moderately important	Important	Very important
Concentrating	Not at all important	Only slightly important	Moderately important	Important	Very important
Remembering things	Not at all important	Only slightly important	Moderately important	Important	Very important
Walking distances farther than inside my home	Not at all important	Only slightly important	Moderately important	Important	Very important
Standing for longer than it takes me to wash dishes	Not at all important	Only slightly important	Moderately important	Important	Very important
Typing or taking notes	Not at all important	Only slightly important	Moderately important	Important	Very important
Doing light housework (like dishwashing, preparing meals, or making a bed)	Not at all important	Only slightly important	Moderately important	Important	Very important
Doing heavy housework (like laundry, yard work, or cleaning a bathtub)	Not at all important	Only slightly important	Moderately important	Important	Very important
Reading	Not at all important	Only slightly important	Moderately important	Important	Very important
Caring for children or other family members	Not at all important	Only slightly important	Moderately important	Important	Very important

2. Some treatments may have side effects that you would prefer to avoid. Rate how important it would be for you to avoid the common side effects listed below.

	Not at all important	Only slightly important	Moderately important	Important	Very important
Depression	Not at all important	Only slightly important	Moderately important	Important	Very important
Weight gain or weight loss	Not at all important	Only slightly important	Moderately important	Important	Very important
Nausea	Not at all important	Only slightly important	Moderately important	Important	Very important
Headaches	Not at all important	Only slightly important	Moderately important	Important	Very important
Other pain or discomfort	Not at all important	Only slightly important	Moderately important	Important	Very important
Trouble sleeping	Not at all important	Only slightly important	Moderately important	Important	Very important
Sexual problems	Not at all important	Only slightly important	Moderately important	Important	Very important
Feeling too tired	Not at all important	Only slightly important	Moderately important	Important	Very important
Urinary problems (incontinence, frequent trips to the bathroom)	Not at all important	Only slightly important	Moderately important	Important	Very important
Bowel problems (diarrhea, constipation)	Not at all important	Only slightly important	Moderately important	Important	Very important

3. Different treatments may require different amounts of time, effort, and money. Rate how concerned you would be about each of the following items.

	Not at all concerned	Only slightly concerned	Moderately concerned	Concerned	Very concerned
Cost	Not at all concerned	Only slightly concerned	Moderately concerned	Concerned	Very concerned
Time needed for treatment	Not at all concerned	Only slightly concerned	Moderately concerned	Concerned	Very concerned
Difficulty of treatment	Not at all concerned	Only slightly concerned	Moderately concerned	Concerned	Very concerned
Number of days needed for the treatment, from start to finish	Not at all concerned	Only slightly concerned	Moderately concerned	Concerned	Very concerned
Paperwork and forms needed to start treatment or be paid back	Not at all concerned	Only slightly concerned	Moderately concerned	Concerned	Very concerned

4. During your treatment, what help will you get from friends and family? (Check all that apply.)

Friends or family will help me get to and from appointments.

Friends or family will help me keep track of my medicines.

Friends or family can give me emotional support during my treatment.

I will be on my own.